Drastic Enophthalmos after Orbital Roof Removal for Tumor: Revisiting the Dogma for When to Consider Orbital Roof Reconstruction and Avoidance of Postoperative Morbidity

Introduction: The orbital walls or roof may need resection for treatment of sphenoorbital meningiomas or other extensive craniofacial tumors involving the orbit and anterior skull base. Firm orbital roof reconstruction is usually not required for a satisfactory cosmetic and clinical outcome if the defect is minimal, especially if the other orbital walls and orbital rim remain intact or repaired. Here, we present a case of invasive undifferentiated squamous cell carcinoma which was resected via a bifrontal craniotomy, as well as a transfacial and transorbital approach. Partial resection of the orbital roof, medial wall, and floor was required for negative margins. Additionally the inferior and superior oblique muscles were sectioned for margins. The orbital floor and medial wall were repaired with alloderm and titanium plating with excellent cosmetic appearance immediately postoperatively. Several hours after the procedure, the patient developed severe enophthalmos requiring surgical repair and ultimately plating of the orbital roof.

Case Details: Our patient is a 68-year-old female who began noticing new-onset right eyelid drooping, facial swelling, nasal congestion, and right face numbness over the course of 2 months. Her primary care physician referred her to ophthalmology who noted right-sided proptosis with increased intraocular pressure. An MRI brain and orbit were obtained at that time and demonstrated a large heterogeneously enhancing mass centered within the right ethmoidal air cells ([Fig. 1]). A biopsy was obtained in otolaryngology clinic showing poorly differentiated squamous cell carcinoma. The patient underwent induction chemotherapy followed by a multidisciplinary approach for surgical resection involving neurosurgery, otolaryngology, and oculoplastics. The procedure included a bifrontal craniotomy, transfacial, and endonasal approach with right lateral rhinotomy, ethmoidectomy, resection of the medial orbital wall, orbital floor, orbital roof, as well as the superior and inferior oblique muscles. Reconstruction included an adipofascial forearm free flap graft, alloderm wrapped orbital floor, and medial wall anchored with titanium synthese implant, and pericranial flap. Immediate post operatively, the patient had excellent cosmetic appearance; however, within several hours, it was noted that her right eye had severe enophthalmos with kinking of the optic nerve ([Fig. 2]). Patient's vision remained intact, but it was decided to return to the operative room for exploration. Ultimately, a nylamid orbital roof implant was placed with satisfactory results ([Fig. 3]).

Conclusion: When treating difficult craniofacial and skull -based tumors, the goal is maximal safe resection limiting morbidity and obtaining a satisfactory cosmetic result with the reconstruction. Historically, literature has supported the practice of not requiring firm orbital roof reconstruction. In certain cases, such as presented here, with resection and reconstruction of additional orbital walls and violation of the periorbita, it is likely necessary to perform a firm orbital roof reconstruction as well to avoid morbidity such as enophthalmos.

Fig. 1 Initial MRI. T1 with contrast demonstrating a heterogeneously enhancing mass within the right ethmoid sinus involving the orbit and anterior skull base. MRI, magnetic resonance imaging.

Fig. 2 Noncontrast CT. Showing right enophthalmos with drastic kinking of the optic nerve. Orbital floor and medial wall reconstruction shown. CT, computed tomography.

Fig. 3 Noncontrast CT. Showing improved enophthalmos and with titanium plating of the orbital floor and medical wall, and a nylamid orbital roof. CT, computed tomography.

No conflict of interest has been declared by the author(s).

Publication History

Article published online:
12 February 2021